title: Clearance of the cervical spine in clinically unevaluable trauma patients.
abstract: METHODS
  Meta-analytic costeffectiveness analysis.
  
  
  OBJECTIVE
  Our goal was to compare the results of different management strategies for trauma patients in whom the cervical spine was not clinically evaluable due to impaired consciousness, endotracheal intubation, or painful distracting injuries.
  
  
  BACKGROUND
  We performed a structured literature review related to cervical spine trauma, radiographic clearance techniques (plain radiography, flexion/extension, CT, and MRI), and complications associated with semirigid collar use.
  
  
  METHODS
  Meta-analytic techniques were used to pool data from multiple sources to calculate pooled mean estimates of sensitivities and specificities of imaging techniques for cervical spinal clearance, rates of complications from various clearance strategies and from empirical use of semirigid collars. A decision analysis model was used to compare outcomes and costs among these strategies.
  
  
  RESULTS
  Slightly more than 7.5% of patients who are clinically unevaluable have cervical spine injuries, and 42% of these injuries are associated with spinal instability. Sensitivity of plain radiography or fluoroscopy for spinal clearance was 57% (95% CI: 57%-60%). Sensitivities for CT and MRI alone were 83% (82%-84%) and 87% (84%-89%), respectively. Complications associated with collar use ranged from 1.3% (2 days) to 7.1% (10 days) but were usually minor and short-lived. Quadriplegia resulting from spinal instability missed by a clearance test had enormous impacts on longevity, quality of life, and costs. These impacts overshadowed the effects of prolonged collar application, even when the incidence of quadriplegia was extremely low.
  
  
  CONCLUSIONS
  As currently used, neuroimaging studies for cervical spinal clearance in clinically unevaluable patients are not cost-effective compared with empirical immobilization in a semirigid collar.
authors.affiliation: Department of Neurosurgery, University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA.
authors.forename: Casey H
authors.initials: CH
authors.lastname: Halpern
authors.forename: Andrew H
authors.initials: AH
authors.lastname: Milby
authors.forename: Wensheng
authors.initials: W
authors.lastname: Guo
authors.forename: James M
authors.initials: JM
authors.lastname: Schuster
authors.forename: Vicente H
authors.initials: VH
authors.lastname: Gracias
authors.forename: Sherman C
authors.initials: SC
authors.lastname: Stein
mesh_terms: D001915:Braces; D002574:Cervical Vertebrae / Q000000981:diagnostic imaging* / Q000293:injuries / Q000473:pathology; D003952:Diagnostic Imaging / Q000191:economics* / Q000379:methods; D006801:Humans; D011237:Predictive Value of Tests; D011859:Radiography; D013124:Spinal Injuries / Q000175:diagnosis* / Q000191:economics* / Q000628:therapy; D014947:Wounds and Injuries / Q000175:diagnosis / Q000191:economics / Q000628:therapy